Summary of Benefits and Coverage - Oregon's Health CO-OP

Transcription

Oregon’s Health CO-OP SiMPLEsilver HSA:
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: 01/01/2015 – 12/31/2015
Coverage for: Small Group | Plan Type: PPO
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan
document at http://www.ohcoop.org/small-group-plans or by calling 1-855-722-8207.
Important Questions
What is the overall
deductible?
Are there other
deductibles for specific
services?
Is there an out–of–pocket
limit on my expenses?
What is not included in
the out–of–pocket
limit?
Answers
$3,000 person/$6,000 family
The deductible applies to all
services except preventive
services.
No.
Yes. For network providers
For non-network providers
Premiums, Balance billing for
Non-Network providers, health
care services or supplies not
covered by Plan
Why this Matters:
Check your policy or plan document to see when the deductible starts over (usually, but
not always, January 1st). See the chart starting on page 2 for how much you pay for covered
services after you meet the deductible.
You don’t have to meet deductibles for specific services, but see the chart starting on page
2 for other costs for services this plan covers.
The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for
your share of the cost of covered services. This limit helps you plan for health care expenses.
Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
Is there an overall
annual limit on what
the plan pays?
No.
The chart starting on page 2 describes any limits on what the plan will pay for specific
covered services, such as office visits.
Does this plan use a
network of providers?
Yes. See
http://www.ohcoop.org/finda-plan/our-provider-pharmacynetworks for a list of network
providers or call 1-855-7228207.
If you use an Network doctor or other health care provider, this plan will pay some or all
of the costs of covered services. Be aware, your Network doctor or hospital may use an
Non-Network provider for some services. Plans use the term in-network, preferred, or
participating for providers in their network. See the chart starting on page 2 for how this
plan pays different kinds of providers.
Do I need a referral to
see a specialist?
No. You don’t need a referral to
You can see the specialist you choose without permission from this plan.
see a specialist.
Are there services this
Yes.
Some of the services this plan doesn’t cover are listed on page 4. See your policy or plan
Questions: Call 1-855-722-8207 or visit us at www.ohcoop.org.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.dol.gov/ebsa/healthreform or call 1-855-722-8207 to request a copy.
OMB Control Numbers 1545-2229,
1210-0147, and 0938-1146
Released on April 23, 2013 (corrected)
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plan doesn’t cover?
Coverage Period: 01/01/2015 – 12/31/2015
document for additional information about excluded services.
• Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
• Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if
the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if
you haven’t met your deductible.
• The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the
allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and
the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)
• This plan may encourage you to use network providers by charging you lower deductibles, copayments and coinsurance amounts.
Common
Medical Event
If you visit a health
care provider’s office
or clinic
If you have a test
Your Cost If
You Use an
Network
Provider
Primary care visit to treat an injury or illness
Specialist visit
Other practitioner office visit
$0
$0
$0
Your Cost If
You Use an
Non-Network
Provider
100% coinsurance
50% coinsurance
50% coinsurance
Preventive care/screening/immunization
$0
100% coinsurance
Diagnostic test (x-ray, blood work)
Imaging (CT/PET scans, MRIs)
$0
$0
50% coinsurance
50% coinsurance
Services You May Need
Limitations & Exceptions
Non-Network, not covered.
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Non-Network, not covered.
Non-Network, not covered. Some
preventive services require costsharing. Certain preventive services
such as immunizations, mammograms,
and cervical cancer screening are
covered with no cost-sharing. For a
complete list of preventive services
covered with no cost-sharing, call 1855-722-8207.
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Common
Medical Event
If you need drugs to
treat your illness or
condition
More information
about prescription
drug coverage is
available at
www.[insert].
If you have
outpatient surgery
Your Cost If
You Use an
Network
Provider
Coverage Period: 01/01/2015 – 12/31/2015
Your Cost If
You Use an
Non-Network
Provider
Generic drugs
$0
100% coinsurance
Preferred brand drugs
$0
100% coinsurance
Non-preferred brand drugs
$0
100% coinsurance
Specialty drugs
0%
100% coinsurance
Facility fee (e.g., ambulatory surgery center)
ASC $0
Hospital $0
50% coinsurance
Physician/surgeon fees
$0
50% coinsurance
Emergency room services
$0
$0
If you need
immediate medical
Emergency medical transportation
$0
50% coinsurance
attention
Urgent care
$0
50% coinsurance
Facility fee (e.g., hospital room)
$0
50% coinsurance
If you have a
hospital stay
Physician/surgeon fee
$0
50% coinsurance
Mental/Behavioral health outpatient services $0
50% coinsurance
If you have mental
Mental/Behavioral health inpatient services
$0
50% coinsurance
health, behavioral
health, or substance Substance use disorder outpatient services
$0
50% coinsurance
abuse needs
Substance use disorder inpatient services
$0
50% coinsurance
If you are pregnant
Prenatal and postnatal care
$0
100% coinsurance
Non-Network Exception: Up to 30
day emergency supply will be covered
with preauthorization.
All terminations of pregnancy services
provided by a licensed provider,
including those for which federal
funding is prohibited, are covered by
this plan.
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Preauthorization required.
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Preauthorization required
Non-Network not covered.
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Common
Medical Event
If you need help
recovering or have
other special health
needs
Your Cost If
You Use an
Network
Provider
Delivery and all inpatient services
Home health care
$0
$0
Your Cost If
You Use an
Non-Network
Provider
50% coinsurance
50% coinsurance
Rehabilitation services
$0
50% coinsurance
Habilitation services
$0
50% coinsurance
Skilled nursing care
$0
50% coinsurance
Tier I $0
Tier II $0
Home $0
Inpatient $0
$0
$0
100% coinsurance
Durable medical equipment
Hospice service
If your child needs
dental or eye care
Coverage Period: 01/01/2015 – 12/31/2015
Eye exam
Glasses
Dental check-up
100% coinsurance
50% coinsurance
100% coinsurance
100% coinsurance
100% coinsurance
–––––––––––none–––––––––––
Preauthorization required
Outpatient services are limited to 30
visits/year. Preauthorization required.
Outpatient services are limited to 30
visits/year. Preauthorization required.
Limited to 60 days/year.
Non-Network not covered.
Respite limited to 30 days.
Limited to 1 visit/year
Limited to 1 pair/year
Not covered.
Excluded Services & Other Covered Services:
Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)
•
Dental Care (Adult)
•
Infertility treatment
•
Long-term care
•
Non-emergency care when traveling outside
the U.S.
•
Private-duty nursing
•
Routine eye care (Adult)
•
Weight loss programs
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Coverage Period: 01/01/2015 – 12/31/2015
Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these
services.)
•
Acupuncture
•
Bariatric surgery
•
•
Cosmetic Surgery, one attempt within 18
months of injury, unless there is medical
necessity
•
Hearing aids for members under 18 years; 19
to 25 years covered if in school
Chiropractic Manipulation, six office visits per
year
•
Routine foot care, only if being treated for
diabetes mellitus
Your Rights to Continue Coverage:
Federal and State laws may provide protections that allow you to keep this health insurance coverage as long as you pay your premium. There are
exceptions, however, such as if:
• You commit fraud
• The insurer stops offering services in the State
• You move outside the coverage area
For more information on your rights to continue coverage, contact the Plan at 1-855-722-8207. You may also contact your state insurance department at
Oregon Insurance Division, Consumer Protection Unit, 350 Winter Street NE, Salem OR 97301-3883. PH: 503-947-7984 or 888-877-4894. EMAIL:
[email protected]. Through the Internet at: http://www.oregon.gov/DCBS/insurance/gethelp/Pages/fileacomplaint.aspx.
Your Grievance and Appeals Rights:
If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For
questions about your rights, this notice, or assistance, you can contact your state insurance department at Oregon Insurance Division, Consumer
Protection Unit, 350 Winter Street NE, Salem OR 97301-3883. PH: 503-947-7984 or 888-877-4894. EMAIL: [email protected]. Through the Internet at:
http://www.oregon.gov/DCBS/insurance/gethelp/Pages/fileacomplaint.aspx.
Does this Coverage Provide Minimum Essential Coverage?
The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan does provide
minimum essential coverage.
Does this Coverage Meet the Minimum Value Standard?
The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This
health coverage does meet the minimum value standard for the benefits it provides.
[Insert heading and applicable tagline(s):
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Coverage Period: 01/01/2015 – 12/31/2015
Language Access Services:
Spanish (Español): Para obtener asistencia en Español, llame al 1-855-722-8207.
TTY (Oregon’s Relay Services): 1-800-735-2900 or 711.
For a language other than English, please call Customer Service at any of the phone numbers above.
––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––––––––
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Coverage Period: 01/01/2015 – 12/31/2015
Coverage Examples
About these Coverage
Examples:
These examples show how this plan might cover
medical care in given situations. Use these
examples to see, in general, how much financial
protection a sample patient might get if they are
covered under different plans.
This is
not a cost
estimator.
Don’t use these examples to
estimate your actual costs
under this plan. The actual
care you receive will be
different from these
examples, and the cost of
that care will also be
different.
See the next page for
important information about
these examples.
Having a baby
Managing type 2 diabetes
(normal delivery)
(routine maintenance of
a well-controlled condition)
 Amount owed to providers: $7,540
 Plan pays $4,390
 Patient pays $3,150
 Amount owed to providers: $5,400
 Plan pays $2,320
 Patient pays $3,080
Sample care costs:
Hospital charges (mother)
Routine obstetric care
Hospital charges (baby)
Anesthesia
Laboratory tests
Prescriptions
Radiology
Vaccines, other preventive
Total
$2,700
$2,100
$900
$900
$500
$200
$200
$40
$7,540
Sample care costs:
Prescriptions
Medical Equipment and Supplies
Office Visits and Procedures
Education
Laboratory tests
Vaccines, other preventive
Total
$2,900
$1,300
$700
$300
$100
$100
$5,400
Patient pays:
Deductibles
Copays
Coinsurance
Limits or exclusions
Total
$3,000
$0
$0
$150
$3,150
Patient pays:
Deductibles
Copays
Coinsurance
Limits or exclusions
Total
$3,000
$0
$0
$80
$3,080
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Coverage Examples
Coverage Period: 01/01/2015 – 12/31/2015
Questions and answers about the Coverage Examples:
What are some of the
assumptions behind the
Coverage Examples?
•
•
•
•
•
•
•
Costs don’t include premiums.
Sample care costs are based on national
averages supplied by the U.S.
Department of Health and Human
Services, and aren’t specific to a
particular geographic area or health plan.
The patient’s condition was not an
excluded or preexisting condition.
All services and treatments started and
ended in the same coverage period.
There are no other medical expenses for
any member covered under this plan.
Out-of-pocket expenses are based only
on treating the condition in the example.
The patient received all care from innetwork providers. If the patient had
received care from out-of-network
providers, costs would have been higher.
What does a Coverage Example
show?
Can I use Coverage Examples
to compare plans?
For each treatment situation, the Coverage
Example helps you see how deductibles,
copayments, and coinsurance can add up. It
also helps you see what expenses might be left
up to you to pay because the service or
treatment isn’t covered or payment is limited.
Yes. When you look at the Summary of
Does the Coverage Example
predict my own care needs?
 No. Treatments shown are just examples.
The care you would receive for this
condition could be different based on your
doctor’s advice, your age, how serious your
condition is, and many other factors.
Does the Coverage Example
predict my future expenses?
No. Coverage Examples are not cost
estimators. You can’t use the examples to
estimate costs for an actual condition. They
are for comparative purposes only. Your
own costs will be different depending on
the care you receive, the prices your
providers charge, and the reimbursement
your health plan allows.
Benefits and Coverage for other plans,
you’ll find the same Coverage Examples.
When you compare plans, check the
“Patient Pays” box in each example. The
smaller that number, the more coverage
the plan provides.
Are there other costs I should
consider when comparing
plans?
Yes. An important cost is the premium
you pay. Generally, the lower your
premium, the more you’ll pay in out-ofpocket costs, such as copayments,
deductibles, and coinsurance. You
should also consider contributions to
accounts such as health savings accounts
(HSAs), flexible spending arrangements
(FSAs) or health reimbursement accounts
(HRAs) that help you pay out-of-pocket
expenses.
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Summary of Benefits and Coverage - Oregon's Health CO-OP

Transcription

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